Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment.

Many procedures have been described for treating lateral epicondylitis with good success. The purpose of this report is to compare 3 operative methods for treatment of recalcitrant lateral epicondylitis-open, arthroscopic, and percutaneous. All patients with lateral epicondylitis who were operated on over a 7-year period were retrospectively reviewed. A minimum of 3 months of conservative care before surgery had failed in these patients, and they had a minimum of 2 years of follow-up. Concomitant pathology, complications, and necessary further care were noted. The outcomes were evaluated preoperatively and postoperatively with the Andrews-Carson score and visual analog scale scores for pain at rest, worst pain, and pain with activity. We included 109 patients in the study: 24 percutaneous, 44 arthroscopic, and 41 open procedures. The mean duration of conservative care was 13.2 months, including 2.5 conservative measures and 1.35 cortisone injections. The mean follow-up was 47.8 months. The preoperative Andrews-Carson score was 160.3. The postoperative Andrews-Carson score was 195. There was a statistically significant difference between preoperative and postoperative Andrews-Carson scores for each of the groups. There were no significant differences among the populations regarding age, gender, dominance, conservative measures used, cortisone injections, recurrences, complications, failures, visual analog scale scores, and preoperative and postoperative Andrews-Carson scores. In addition, no difference in outcome scores was noted when intraarticular and concomitant pathology was addressed in comparison to the population in which tendinosis alone was addressed. Open, arthroscopic, and percutaneous treatments of lateral epicondylitis offer 3 highly effective ways for the clinician to address this common clinical problem.

A biomechanical analysis of controllable intraoperative variables affecting the strength of rotator cuff repairs at the suture-tendon interface.

BACKGROUND: The tissue-suture interface remains the weakest aspect of a rotator cuff repair, highlighting the importance of identifying techniques to improve stitch strength. Choice of suture-passing devices, size of the tissue bite, and stitch configuration are variables that may influence stitch strength and therefore repair stability. PURPOSE: To evaluate the effect that size of the tissue penetrator device and tissue bite size have upon the holding strength of commonly used stitches. STUDY DESIGN: Controlled laboratory study. METHODS: Three different-sized tissue-penetrating devices, small circular, midsized circular, and large rectangular, were used to place sutures in 192 infraspinatus tendon grafts of sheep. Tissue bite sizes of either 0.5 cm or 1.0 cm for 4 different stitches, a simple, mattress, modified Mason-Allen (MMA), and massive cuff (MAC) stitch, were tested. Grafts were cyclically loaded and then loaded to failure. Mixed multivariate regression analysis was used to test the effect of instrument, bite size, and stitch configuration on peak-to-peak displacement, cyclic elongation, and load to failure. RESULTS: The average ultimate load to failure with the smallest penetrating device was 112 N, significantly higher than with both the midsized (95 N) and large devices (91 N) (P < .001). The average load to failure was 31 N higher for a 1.0-cm bite size when compared with a 0.5-cm bite size (P < .001). The largest load-to-failure differences were found with the type of stitch placed: simple, 48 N; mattress, 69 N; MMA, 130 N; and MAC, 152 N (all P < .02). For simple and mattress stitches, each additional pass of the suture increased the load to failure by 21 N. In MMA and MAC stitches, an additional pass resulted in an increase in the load to failure by 50 N. Cyclic elongation did not differ by instrument type (all P > .5). The elongation of stitches with a 1.0-cm bite size was 0.14 mm higher than stitches with a 0.5-cm bite size (P < .001). No meaningful difference in peak-to-peak displacement was seen for bite size, instrument type, or stitch construct. CONCLUSION: The strength of rotator cuff stitches was significantly affected by the different-sized tissue-penetrating instruments and size of the bite. However, the greatest predictor of time-zero stitch strength is the type of stitch placed. CLINICAL RELEVANCE: This study highlights the importance of stitch configuration in the repair of rotator cuff tears.

Biomechanical evaluation of 3 arthroscopic self-cinching stitches for shoulder arthroscopy: the lasso-loop, lasso-mattress, and double-cinch stitches.

BACKGROUND: The tissue-suture interface remains the most common site of failure in rotator cuff repairs. Improving stitch strengths may lead to lower failure rates. PURPOSE: To compare biomechanical properties of 3 self-cinching stitches to the simple, mattress, modified Mason-Allen, and massive cuff stitches. STUDY DESIGN: Controlled laboratory study. METHODS: In sum, 336 sheep infraspinatus tendon grafts were randomized among 7 stitches. Each graft was cyclically loaded on a mechanical testing system from 5 to 30 N for 20 cycles and then loaded to failure. A mixed-effect multivariate regression model was used to test significance of suture type on cyclic elongation, peak-to-peak displacement, and ultimate load. Estimated means and standard deviations are reported from the regression model. RESULTS: Ultimate load for the simple stitch was significantly lower than for the other stitches. The lasso-loop and mattress stitch demonstrated similar ultimate loads. The double-cinch had a higher ultimate load than the lasso-loop or mattress stitch, although it was significantly weaker than the modified Mason-Allen, lasso-mattress, and massive cuff. The lasso-mattress had a superior ultimate load to the modified Mason-Allen and a similar ultimate load to the massive cuff stitch. One significant difference was found in cyclic elongation (1.42 mm for the simple to 1.80 mm for the double-cinch), and the cinching mechanism accounted for 0.2-mm higher elongation. CONCLUSION: Self-cinching stitches lead to superior tissue-holding strength at the tissue-suture interface when compared with equivalent non-self-cinching stitches. Self-cinching stitches have greater elongation values. How these differences in cyclic elongation clinically influence gap formation at the repair site is unknown. The greater displacement seen in the self-cinching stitches is a potential concern because minimal gap formation is desired for a strong repair. CLINICAL RELEVANCE: The lasso-loop stitch is a stronger alternative to a simple stitch, and the double-cinch and lasso-mattress stitches are stronger alternatives to a mattress stitch.